CVA TESST 5
A patient is diagnosed with tension headaches. What explanation of tension headaches should the clinic nurse provide? a) Tension headaches are caused by blood sugar fluctuations that result from excessive stress." b) "Tension headaches are caused by stress, which causes cerebral vessel constriction." c) "Tension headaches result from release of pain mediators in the periphery." d) "Tension headaches are a result of stress and sustained muscle contraction of the head and neck."
"Tension headaches are a result of stress and sustained muscle contraction of the head and neck."
A patient awakens after a seizure and remembers smelling something like dead fish before it occurred. Which of the following responses by the nurse is best? a) "Most people see a flash of light before a seizure; if this occurs, you should get to safety immediately." b) "Today is Friday; the hospital always cooks fish on Fridays." c) "You were probably hallucinating; I will ask for an order for an antihallucinatory agent." d) "The smell of dead fish might be your aura; you should call for help immediately if you smell it again."
"The smell of dead fish might be your aura; you should call for help immediately if you smell it again."
A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first? a) Alteration in level of consciousness (LOC) b) Slurred speech c) Decreased heart rate d) Bradycardia
A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first? a) Bradycardia b) Alteration in level of consciousness (LOC) c) Decreased heart rate d) Slurred speech
A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in ICP. What nursing intervention would be appropriate for this patient? a) Absolute bed rest in a quiet non-stimulating environment. b) Encourage family visitation to decrease anxiety. c) Range-of-motion exercises to prevent contractures. d) Encourage independence with ADLs to promote self-esteem.
Absolute bed rest in a quiet non-stimulating environment.
A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? a) Administer stool softeners. b) Provide sensory stimulation. c) Encourage coughing and deep breathing. d) Position the client with the head turned toward the side of the brain tumor.
Administer stool softeners.
A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the medical treatment to include which of the following? a) Anticoagulant therapy b) Cholesterol-lowering drugs c) Monthly prothrombin levels d) Carotid endarterectomy
Anticoagulant therapy
A patient is admitted to the hospital with a fractured femur and possible head injury. Vital signs on admission were blood pressure 128/72 mm Hg, pulse 90 beats/min, respirations 16 breaths/min. Four hours after admission, the nurse is checking vital signs as part of the hourly assessment. Which of the following vital signs most likely indicate the presence of increased intracranial pressure? a) Blood pressure 160/90 mm Hg, pulse 112 beats/min, respirations 16 breaths/min b) Blood pressure 172/68 mm Hg, pulse 42 beats/min, respirations 10 breaths/min c) Blood pressure 130/72 mm Hg, pulse 50 beats/min, respirations 24 breaths/min d) Blood pressure 100/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min
Blood pressure 172/68 mm Hg, pulse 42 beats/min, respirations 10 breaths/min
While making your initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells you the pain is behind his right eye, which is red and tearing. What type of headache would you suspect this client of having? a) Migraine b) Sinus c) Tension d) Cluster
Cluster
A client with atrial fibrillation is placed on Coumadin to reduce the potential of developing a cerebrovascular accident (CVA). The international normalized ratio (INR) is 1.5. What does this finding indicate to the nurse? a) Therapeutic range is achieved. b) Coumadin will be decreased. c) INR is too high. d) Coumadin will be increased.
Coumadin will be increased.
A nursing student is writing a care plan for a newly admitted patient who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the patient's plan of care? a) Hyperthermia b) Adult failure to thrive c) Post-trauma syndrome d) Disturbed sensory perception
Disturbed sensory perception
A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what? a) Blood pressure of ≥ 180/110 mm Hg b) Evidence of stroke evolution c) Evidence of hemorrhagic stroke d) Previous thrombolytic therapy within the past 12 months
Evidence of hemorrhagic stroke
A patient is admitted to a medical unit with a cerebrovascular accident (stroke). The patient is flaccid on the left side and is unable to speak, but seems to understand everything the nurse says. What phenomenon is the patient experiencing? a) Expressive aphasia b) Mixed aphasia c) Receptive aphasia d) Sensory aphasia
Expressive aphasia
A 22-year-old man is being closely monitored in the neurological ICU after suffering a basal skull fracture during an assault. The nurse's hourly assessment reveals the presence of a new blood stain on the patient's pillow that is surrounded by a stain that is pale yellow in color. The nurse should follow up this finding promptly because it is suggestive of: a) An epidural hematoma b) Leakage of cerebrospinal fluid (CSF) c) Meningitis d) Increasing intracranial pressure (ICP)
Leakage of cerebrospinal fluid (CSF)
A patient diagnosed with Transient Ischaemic attack (TIA) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done to what? a) Decrease cerebral oedema. b) Determine the cause of the TIA. c) Prevent a stroke by removing atherosclerotic plaques blocking cerebral flow. d) Prevent seizure activity that is common following a TIA.
Prevent a stroke by removing atherosclerotic plaques blocking cerebral flow.
A patient who has had a CVA is unable to understand what the nurse is saying and appears frustrated. How should the nurse describe this when documenting the finding? a) Confusion b) Expressive aphasia c) Dysphagia d) Receptive aphasia
Receptive aphasia
A client is diagnosed with tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? a) Relaxes muscles b) Relieves migraines c) Increases appetite d) Reduces hypotension
Relaxes muscles
A patient is admitted to the stepdown unit after 3 days in the intensive care unit recovering from an epidural bleed. The nurse explains to the family that an epidural bleed occurs in which part of the brain? a) Space between the dura and the skull b) Circle of Willis c) Space below the dura d) Spinal meninges
Space between the dura and the skull
Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? a) Intracerebral b) Subdural c) Cerebral d) Epidural
Subdural
A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement? a) "TIA symptoms are shortlived and resolve within 24 hours". b) "People who experience a TIA will develop a stroke". c) "TIA is a warning sign. Let's talk about lowering your risks." d) "I sense that you are happy it was not a stroke".
TIA is a warning sign. Let's talk about lowering your risks."
A client is having a tonic-clonic seizure. What should the nurse do first? a) Elevate the head of the bed. b) Restrain the client's arms and legs. c) Take measures to prevent injury. d) Place a tongue blade in the client's mouth.
Take measures to prevent injury.
When documenting a seizure, which information is most important to include? a) The client's mood just before the seizure b) The client's comment after the seizure c) The time the seizure started d) The duration of the seizure
The duration of the seizure
An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following? a) Two hours b) One hour c) Three hours d) Six hours
Three hours
A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? a) To determine the cause of the TIA b) To decrease cerebral edema c) To remove atherosclerotic plaques blocking cerebral flow d) To prevent seizure activity that is common following a TIA
To remove atherosclerotic plaques blocking cerebral flow
A client is hospitalized when they present to the Emergency Department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to their presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? a) Transient ischemic attack b) Cerebral aneurysm c) Left-sided stroke d) Right-sided stroke
Transient ischemic attack
A client is being assessed for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA? a) Respiratory distress b) Unilateral ptosis c) Severe headache d) Nausea and vomiting
Unilateral ptosis
In your role as a public health nurse, you offer public education in high school classes on personal responsibility in preventing head injuries as a way of life. While avoiding alcohol and drugs not only complies with existing law for minors, it also is an available intervention to prevent head injuries. Which of the following are measures available to prevent head injuries? a) Using seatbelts b) Holding infants tightly while riding in an automobile c) Lowering neck restraints on seatbacks d) None of the options are correct
Using seatbelts
A 32-year-old client has a 12-year history of migraine headaches. As she discusses her most recent headaches, she voices frustration over how her life is at the mercy of these headaches. As she describes the characteristics of her head pain, you begin to discuss the potential causes of her migraines. What would you indicate to the client is the origin of her migraines? a) Endocrine b) Light c) Muscular d) Vascular
Vascular
A mother brings her 6-year-old to the emergency department (ED) after the child fell off the bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be? a) "A concussion is a blow to the head that is hard enough for the brain to bounce off the other side of the skull." b) "A concussion is a blow to the head that is minor and has no real consequences." c) "A concussion is a blow to the head that bruises the brain." d) "A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain."
"A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain."
Which of the following would the nurse recognize as being the least likely reason for the procedure shown in the accompanying image? a) To make a bone flap in the skull b) To confirm a skull fracture c) To aspirate a brain abscess d) To evacuate a hematoma
To confirm a skull fracture
Dysphasia is a) the difficulty/inability to communicate through speech b) a dimness of loss of vision c) difficulty communicating through eye contact d) difficulty swallowing
the difficulty/inability to communicate through speech
Choice Multiple question - Select all answer choices that apply. A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply. a) Epistaxis (nosebleed) b) Visual disturbances c) Confusion d) Sudden ear pain e) Sudden numbness
• Visual disturbances • Confusion • Sudden numbness
